Getting to Zero in San Francisco Consortium. Zero new HIV infections Zero HIV deaths Zero stigma and discrimination

Transcription

1 Getting to Zero in San Francisco Consortium Zero new HIV infections Zero HIV deaths Zero stigma and discrimination

2 Agenda 1. Welcome 2. Policy Updates 3. SF HIV Epidemiology Data 4. Presentation, Panel + Discussion: On demand PrEP

3 Acknowledgments Welcome Diane Jones! New Steering Committee Members Johanna Brown Shaddai Cuestas-Martinez Lori Thoemmes Jacob Moody Mike Shriver Jessie Murphy

4 Policy Update

5 5 HIV EPIDEMIOLOGY ANNUAL REPORT 2016 Getting to Zero Consortium Meeting September 28, 2017 Susan Scheer, PhD, MPH HIV Epidemiology Section

6 Key Highlights Outline Many encouraging trends New HIV diagnoses declined Rate of new diagnoses among men for declined Linkage to care improved Viral suppression improved Time to ART initiation improved Time to viral suppression improved Undiagnosed HIV low No new diagnoses among babies or children since 2005 but still significant disparities Highest number and rate of new diagnoses overall among: MSM Highest rate of new diagnoses by race among: African-Americans Care outcomes worse for: Women Trans women African-Americans Homeless people The Gaps are Closing beginning to see care and prevention outcomes improve even in demographic groups with disparities 6

7 Encouraging Trends among Persons Living with HIV and New Diagnoses Overall 93% of PLWH are aware of their HIV status New diagnoses decreased 16% between Number of deaths is leveling Survival is improving; 63% of PLWH >50yrs Late diagnoses declined from 21% in 2012 to 16% in

8 Number of Cases No Perinatal or Pediatric Cases (age<13) diagnosed since Year of HIV Diagnosis

9 Improvements in the HIV Care Continuum 9

10 Median Days Faster Time to Care Indicators Diagnosis 2013 Diagnosis 2014 Diagnosis Diagnosis DX to Care Care to ART ART to VSP DX to VSP 10

11 Underlying causes of death 3 time periods, Year of Death N=1,310 N=971 N=973 Underlying Cause of Death 1 Number (%) Number (%) Number (%) HIV 756 ( 57.7 ) 462 ( 47.6 ) 392 (40.3 ) Non-AIDS cancer 132 ( 10.1 ) 117 ( 12.0 ) 133 (13.7 ) Lung cancer 43 ( 3.3 ) 35 ( 3.6 ) 37 ( 3.8 ) Liver cancer 2 nd leading 26 ( 2.0 ) 18 ( 1.9 ) 17 ( 1.7 ) Anal cancer cause of death 5 ( 0.4 ) 7 ( 0.7 ) 9 ( 0.9 ) Pancreatic cancer 6 ( 0.5 ) 3 ( 0.3 ) 7 ( 0.7 ) Colon cancer 7 ( 0.5 ) 8 ( 0.8 ) 5 ( 0.5 ) Leukemia 1 ( 0.1 ) 2 ( 0.2 ) 5 ( 0.5 ) Hodgkins lymphoma 1 ( 0.1 ) 1 ( 0.1 ) 2 ( 0.2 ) Rectal cancer 8 ( 0.6 ) 3 ( 0.3 ) 2 ( 0.2 ) Accident 102 ( 7.8 ) 116 ( 11.9 ) 103 (10.6 ) Drug overdose 71 ( 5.4 ) 95 ( 9.8 ) 88 ( 9.0 ) Heart disease 89 ( 6.8 ) 86 ( 8.9 ) 86 ( 8.8 ) Coronary heart disease 52 ( 4.0 ) 39 ( 4.0 ) 43 ( 4.4 ) Cardiomyopathy 10 ( 0.8 ) 2 ( 0.2 ) 7 ( 0.7 ) Diseases of arteries 2 ( 0.2 ) 4 ( 0.4 ) 2 ( 0.2 ) Suicide 45 ( 3.4 ) 38 ( 3.9 ) 34 ( 3.5 ) Liver disease 27 ( 2.1 ) 25 ( 2.6 ) 23 ( 2.4 ) Liver cirrhosis 15 ( 1.1 ) 13 ( 1.3 ) 12 ( 1.2 ) Alcoholic liver disease 10 ( 0.8 ) 11 ( 1.1 ) 8 ( 0.8 ) Chronic obstructive pulmonary disease 24 ( 1.8 ) 17 ( 1.8 ) 21 ( 2.2 ) Assault 8 ( 0.6 ) 5 ( 0.5 ) 13 ( 1.3 ) Diabetes 6 ( 0.5 ) 5 ( 0.5 ) 12 ( 1.2 ) Cerebrovascular disease 8 ( 0.6 ) 10 ( 1.0 ) 11 ( 1.1 ) Mental disorders due to substance use 37 ( 2.8 ) 14 ( 1.4 ) 11 ( 1.1 ) Viral hepatitis 14 ( 1.1 ) 9 ( 0.9 ) 8 ( 0.8 ) Renal disease 5 ( 0.4 ) 5 ( 0.5 ) 7 ( 0.7 ) Undetermined intent 3 ( 0.2 ) 4 ( 0.4 ) 4 ( 0.4 ) Septicemia 4 ( 0.3 ) 3 ( 0.3 ) 3 ( 0.3 ) HIV-related causes of death declining Drug overdoses 3 rd leading cause of death 1 Deceased cases diagnosed with HIV infection that lack cause of death information are not represented in this table.

12 Trends in New HIV Diagnoses by Race 12

13 Rate per 100,000 Health Disparities Rate of New Diagnoses among Men Men (N=193) White African American Latino Asian/Pacific Islander AA men (96/100,000) Latino men (77/100,000) White men (39/100,000) Rates declining in AA, Latino and White men Year of HIV Diagnosis

14 Health Disparities Rate of New HIV Diagnoses among Women Women (n=25) Rate of new diagnoses highest in AA women (43/100,000) Slightly higher than White men

15 % of Late Diagnoses Health Disparities Late HIV Diagnosis by Race 35% 30% 25% 20% 15% 10% 2012 Diagnosis 2013 Diagnosis 2014 Diagnosis 2015 Diagnosis 2015 Overall 20% 17% 16% 13% 23% 19% 17% 12% 22% 19% 15% 14% 29% 25% 24% 11% 32% 16% 5% 0% White African American Latino API 0% Ages 50+ have highest proportion of late diagnoses 33% vs 16% overall 15

16 Survival Probability Health Disparities Survival after AIDS 3-year survival 5-year-survival 5-year overall 100% 90% 80% 70% 90% 87% 86% 80% 93% 92% 92% 90% 92% 90% 83% 76% 88% 87% 83% 84% 90% 87% 86% 81% 95% 90% 87% 60% 50% 40% 30% 20% 10% 0% 0% 16

17 Health insurance status at HIV diagnosis by race/ethnicity MediCal 14% [CATEGO VA RY NAME] 1% <1% HSF 3% Other Public (not specified) 2% Missing 11% Medicare 3% White (N=330) None 21% Latino (N=254) Private 45% Private 18% African American (N=106) None 19% Other (N=144) Missing 11% MediCal 40% Other Public (not specified) 5% HSF 5% Jail 2% VA 1% None 29% Private 36% None 32% Private 35% Medicare 1% MediCal 13% VA 1% HSF 7% Missing 7% Other Public (not specified) 3% Medicare 1% MediCal 15% Missing 14% Other HSF Public (not 3% VA specified) 1% 2%

18 Health Disparities Viral Suppression 18

19 Homeless persons diagnosed with HIV compared to all persons diagnosed with HIV Homeless HIV Cases HIV Cases Number (%) Number (%) Total 502 4,574 Gender Male 380 ( 76 ) 4,090 (89 ) Female 72 ( 14 ) 340 ( 7 ) Trans Female 50 ( 10 ) 144 ( 3 ) Race/Ethnicity White 216 ( 43 ) 2,215 (48 ) African American 138 ( 27 ) 630 (14 ) Latino 97 ( 19 ) 1,069 (23 ) Asian/Pacific Islander 13 ( 3 ) 442 (10 ) Other/Unknown 38 ( 8 ) 218 ( 5 ) Transmission Category MSM 160 ( 32 ) 3,237 (71 ) PWID 126 ( 25 ) 302 ( 7 ) MSM-PWID 167 ( 33 ) 625 (14 ) Heterosexual 35 ( 7 ) 278 ( 6 ) Other/Unidentified 14 ( 3 ) 132 ( 3 ) Age at Diagnosis (Years) ( <1 ) 16 (<1 ) ( 15 ) 550 (12 ) ( 19 ) 756 (17 ) ( 25 ) 1,438 (31 ) ( 24 ) 1,204 (26 ) ( 16 ) 610 (13 ) 19

20 Closing the Gap Populations with higher viral suppression after LINCS intervention 67% 68% 63% 63% 31%

21 % of Virally Suppressed w/in 12 Months of Dx Closing the Gap Viral Suppression Trends in Newly Diagnosed by Race/Ethnicity 100% Overall 80% 60% 81% 76% 70% 64% 60% 69% 78% 79% 74% 68% 86% 81% 74% 69% 77% 40% 51% 53% 20% 0% White African American Latino Asian/Pacific Islander 0%

22 Year of HIV Diagnosis Closing the Gap Time from HIV Diagnosis to Viral Suppression by Housing Status, , San Francisco Median days from diagnosis to viral suppression Homeless Housed Preliminary data; subject to change

23 Positive Trends Summary Encouraging trends are not slowing; plus new improvements Overall positive direction: new diagnoses, deaths, survival, late diagnoses, and HIV care continuum steps including faster time to care indicators Improvement Needed Health disparities persist. Not all San Franciscans are being reached or experiencing the same improvements Women, trans women, African-Americans, MSM and, in particular, the homeless experiencing many health disparities including: disproportionately diagnosed Poorer treatment and care outcomes Poorer survival Gaps are Closing Many disparities are improving; prevention and care indicators are improving even in demographic groups with relatively poor outcomes Number and rates of new diagnoses converging by race

24

25 UCSF Health Disparities Core UCSF Gladstone Center for AIDS Research Our mission is to support, direct and advise those working to reduce the health disparities in prevention and care and promote resilience in Bay Area communities most impacted by HIV (including LGBTQ, minority and people of color). For more information contact Lauren Sterling at (415) , or visit CFAR.UCSF.edu

26 Zero new HIV infections Zero HIV deaths Zero stigma and discrimination On demand PrEP Darpun Sachdev, MD Medical Director, LINCS SF City Clinic San Francisco Department of Public Health

27 What is on-demand PrEP? Non daily PrEP terms Intermittent Event/sex driven As-needed What it s not? Not a morning after pill Not disco dosing

28 What hasn t changed? CDC continues to recommend daily PrEP No randomized studies in the United States studying on-demand PrEP FDA review only included IPrEX and Partners PrEP Daily PrEP is the only recommended option for cis-women On-demand PrEP does not prevent side effects Active group in IPERGAY had more gastrointestinal adverse events (14% vs 5%; p=0 002) and renal adverse events (18% vs 10%; p=0 03) than the placebo group In open label extension, 14% reported GI adverse events Unclear if these symptoms are transient or improve over time as with daily dosing

29 What s changed? A new analysis of IPERGAY study evaluated 269 patients (134 person-yrs) who took ondemand PrEP less frequently (<15 pills a month) and found no transmissions in active arm v. 6 infections in placebo arm 1 Real-life experience to date (N~1950) France: 57% of patients choose ondemand 2 Montreal: 22% of patients choose ondemand 3 Amsterdam: 27% choose on-demand ~1/4 switched from daily (reasons: less sex, aversion to daily meds) 4 IPERGAY analysis (IAS 2017) Median number of sex acts/mo: 5 Median number of pills/mo: 9.5 Compared to people choosing daily regimens people who chose on-demand PrEP were: Older Less likely to be in a serodiscordant relationship Fewer casual partners 1. Antoni G, et al. IAS Paris, France. Poster #TUAC0102, 2. Molina JM, et al. IAS Paris, France. Poster #WEPEC093, 3.Greenwald, et al. Adherence Miami, USA. 4. Zimmerman et al. IAS Poster# WEAC0106LB

30 % Sex Events Covered HPTN 067 ADAPT: Clinical Trial of Non-Daily Use of Oral FTC/TDF for PrEP in MSM Harlem and Bangkok N=179 (Harlem/NYC) MSM 100 Daily Time-driven Event-driven % complete coverage % only pre-sex dose % only post-sex dose no coverage D/T and D/E p = 0.01; T/E p =0.47, global p = 0.03 Coverage: >1 pill taken in the 4 days before sex >1 pill taken in the 24 hours after sex Holtz T, IAS Paris, France. Symposia #MOSY0805 6

31 Does pharmacology support on demand dosing for MSM? Yes if.. 1. the right drug 2. to the right biological site(s) 3. at the right concentration(s) 4. for the right length of time Non human primate data require post dose for efficacy Colorectal tissue Pharmacology supports on-demand dosing for anal sex. Data do not support this regimen for vaginal sex. We have very little data for trans women and men. Kashuba A, IAS 2017, France, Paris. Symposium #MOSY0803

32 Adherence to on-demand PrEP v. daily PrEP Decision to take PrEP On-demand PrEP Assessment on a day-to-day basis Daily PrEP Assessment of periodic risk Adherence cue Planned Sex Daily habit Unique barriers - Unplanned sex - Desire to pick and choose with certain partners - Aversion to daily pill - Taking PrEP when not having sex Modified from Haberer IAPAC

33 How often do MSM plan sex? US online survey, 1013 MSM Last anal sex planned? Unplanned Planned % How far ahead planned? Volk et al, JAIDS 2012; 61:

34 How well do MSM predict sex? The Hope Springs Eternal study (Parsons et al, JAIDS 2015;68:454-55) 92 HIV negative MSM asked to predict sex with casual partner x 30d Much better at predicting when they WOULDN T have sex than when they would.

35 Practical Considerations of On Demand PrEP (MSM only, off-label) Emphasize emergency PEP (28 days) and condoms if missed doses Continue q3mo HIV and rectal/pharyngeal/urine STD testing NOT INTENDED FOR Cis- or trans-women Decreasing (renal/bone) toxicity Patterns of sex Have infrequent (<once/week) sex event Ability of sex planning / have control over planning for sex with sexual partners Pros Fewer doses Alternative for individuals who do not want to take a daily pill Cons Need to carry tablets at all times (pre/post-sex dose) Complicated regimen (Need 2 hours window pre-sex) Need to use this strategy uniformly with all sex acts, don t pick and choose with certain partners Potential for resistance if seroconvert with partner off PrEP then take on-demand dosing with other sexual partners Loss of forgiveness of TDF/FTC with on-demand dosing: consider the implications of switching Data do not suggest decreased side effects

36 Panel + Discussion: On-demand PrEP

37 On demand PrEP: Dosing Strategies

38 On-demand dosing: If you have sex once a week

39 On-demand dosing: Sex several times over a few days

40 Sex several times, then more sex less than 7 days after the last PrEP dose

41 Join the consortium: Quarterly consortium meetings, committee meetings, as well as other GTZ events are listed on the calendar: